HIV and Hepatitis B or HIV and Hepatitis B or C co-infectionC co-infectionPreliminary results of surveyPreliminary results of survey

BHIVA Audit Sub-CommitteeBHIVA Audit Sub-Committee

Dr Margaret Johnson (chairperson)Dr Margaret Johnson (chairperson)Dr Gary Brook (vice-chairperson)Dr Gary Brook (vice-chairperson)Dr Hilary Curtis (audit co-ordinator)Dr Hilary Curtis (audit co-ordinator)

J Anderson, R Brettle, P Bunting, D Daniels, A J Anderson, R Brettle, P Bunting, D Daniels, A DeRuiter, S DeSilva, A Freedman, B Gazzard, C DeRuiter, S DeSilva, A Freedman, B Gazzard, C O’Mahony, C McDonald, E Monteiro, D Mital, F O’Mahony, C McDonald, E Monteiro, D Mital, F Mulcahy, A Pozniak, C Sabin, A Sullivan, A Tang, Mulcahy, A Pozniak, C Sabin, A Sullivan, A Tang, G Tudor-Williams, J Welch, E WilkinsG Tudor-Williams, J Welch, E Wilkins

Aims and MethodsAims and Methods

To assess the impact and usefulness of To assess the impact and usefulness of BHIVA guidelines for the management of HIV BHIVA guidelines for the management of HIV and hepatitis B or C co-infection.and hepatitis B or C co-infection.

Questionnaire survey of clinical centres Questionnaire survey of clinical centres providing adult HIV care in the UK and providing adult HIV care in the UK and Ireland, conducted October 2003-January Ireland, conducted October 2003-January 2004.2004.

ParticipationParticipation

Responses were received from 100 clinical Responses were received from 100 clinical centres:centres:

19 in London NHS region, 81 outside19 in London NHS region, 81 outside 6 exclusively haemophilia centres, 25 mixed, 6 exclusively haemophilia centres, 25 mixed,

68 not haemophilia, 1 not stated.68 not haemophilia, 1 not stated.

HIV Caseloads by CentreHIV Caseloads by Centre

1-50

51-100

101-200

201-500

501+

Not stated

Down/sameUp 0-5%

Up 5-10%

Up 10-15%Up >15%

Not stated

NB six of the eight centres reporting no growth were exclusive haemophilia centres.

Number of HIV patients Change in HIV caseload over preceding year

Usefulness of GuidelinesUsefulness of Guidelines

Of the 100 respondents, 87 had read BHIVA’s Of the 100 respondents, 87 had read BHIVA’s guidelines for both hepatitis B (HBV) and C (HCV) guidelines for both hepatitis B (HBV) and C (HCV) and one had only read those for HCV. Among and one had only read those for HCV. Among those who’d read the respective guidelines:those who’d read the respective guidelines:

56 found the HBV guidelines “very” useful 56 found the HBV guidelines “very” useful and 29 “quite” useful.and 29 “quite” useful.

49 found the HCV guidelines “very” useful 49 found the HCV guidelines “very” useful and 29 “quite” useful.and 29 “quite” useful.

Level of ExperienceLevel of Experience

When invited to comment on the survey, five of When invited to comment on the survey, five of the 100 respondents volunteered the information the 100 respondents volunteered the information that no HIV patient at their centre had yet required that no HIV patient at their centre had yet required treatment for HCV, and 11 said they would refer treatment for HCV, and 11 said they would refer such patients elsewhere.such patients elsewhere.

21 respondents had referred at least one patient 21 respondents had referred at least one patient to be assessed for liver transplantation, including to be assessed for liver transplantation, including those from five of six exclusive haemophilia those from five of six exclusive haemophilia centres.centres.

Hepatitis B: Estimated PrevalenceHepatitis B: Estimated Prevalence

44 respondents estimated HBV prevalence 44 respondents estimated HBV prevalence among their HIV patients as 0-3%among their HIV patients as 0-3%

32 estimated 4-6%32 estimated 4-6% 12 estimated 7-9%12 estimated 7-9% 7 estimated >10%. 7 estimated >10%.

Five did not know or did not answer.Five did not know or did not answer.

HBV Vaccine ScheduleHBV Vaccine Schedule

Preferred vaccination schedules for HBV in patients with Preferred vaccination schedules for HBV in patients with HIV were as follows:HIV were as follows:

0, 1, 6 months: 44 respondents including 6 of the 0, 1, 6 months: 44 respondents including 6 of the seven exclusive haemophilia centresseven exclusive haemophilia centres

0, 1, 2, 12 months: 23 respondents.0, 1, 2, 12 months: 23 respondents. 0,1, 3 weeks, 12 months: 23 respondents0,1, 3 weeks, 12 months: 23 respondents

One respondent specified 0,1,3 weeks, 12 months for One respondent specified 0,1,3 weeks, 12 months for patients at continuing risk and 0, 1, 2, 12 months for the patients at continuing risk and 0, 1, 2, 12 months for the remainder. Nine did not answer.remainder. Nine did not answer.

HBV Vaccine Schedule (cont)HBV Vaccine Schedule (cont)

Note that 23 respondents opted for the 0, 1, 3 Note that 23 respondents opted for the 0, 1, 3 week, 12 month schedule which has not been week, 12 month schedule which has not been tested in people with HIV.tested in people with HIV.

However it is the schedule recommended in DoH However it is the schedule recommended in DoH and CEG guidelines for GU clinic attendees.and CEG guidelines for GU clinic attendees.

HBV/HIV ManagementHBV/HIV Management

0

10

20

30

HIV unit Localhepatology/

gastroenterologyunit

Regionalhepatology unit

Joint hepatology/HIV clinic

Other Not sure / noanswer

HBV

Num

ber

of c

entr

es

Access to HBV DNA TestingAccess to HBV DNA Testing

17 respondents reported restrictions on access to 17 respondents reported restrictions on access to HBV DNA testing:HBV DNA testing:

8 relating to lack of local availability8 relating to lack of local availability 4 to financial restrictions4 to financial restrictions 3 both availability and financial restrictions3 both availability and financial restrictions 2 other.2 other.

Liver Biopsy in HBV Co-infectionLiver Biopsy in HBV Co-infection

Fifteen respondents said they would offer liver Fifteen respondents said they would offer liver biopsy to most HIV/HBV patients, unless contra-biopsy to most HIV/HBV patients, unless contra-indicated. indicated.

28 would biopsy those considered for HBV 28 would biopsy those considered for HBV therapy, 18 those with severe liver disease, and therapy, 18 those with severe liver disease, and one both these categories.one both these categories.

11 reported other approaches and 27 were not 11 reported other approaches and 27 were not sure or did not answer.sure or did not answer.

HBV Therapy in Patients whose HIV HBV Therapy in Patients whose HIV does not require Treatmentdoes not require Treatment

0

10

20

30

40

Start ART early,include

lamivudine/tenofovir

Interferon None Adefovir Other (mostly referelsewhere)

Lamivudine

Num

ber

of c

entr

es

HBV Therapy in Patients whose HIV HBV Therapy in Patients whose HIV does not require Treatment (cont)does not require Treatment (cont)

Multiple answers were permitted:Multiple answers were permitted: 27 centres chose starting ART with 27 centres chose starting ART with

lamivudine/tenofovir as their only option.lamivudine/tenofovir as their only option. 7 chose interferon and one adefovir as their 7 chose interferon and one adefovir as their

only option.only option. One chose lamivudine as their only option, One chose lamivudine as their only option,

and a total of 3 chose lamivudine but and a total of 3 chose lamivudine but notnot early ART with a lamivudine/tenofovir early ART with a lamivudine/tenofovir combination.combination.

ART in Patients with Untreated HBVART in Patients with Untreated HBV

0

20

40

60

80

Lamivudine andtenofovir

Lamivudine Tenofovir Neither lamivudinenor tenofovir

Other

Num

ber

of c

entr

es

ART in Patients with Untreated HBV ART in Patients with Untreated HBV (cont)(cont)

Again, multiple answers were possible:Again, multiple answers were possible: 47 centres selected lamivudine/tenofovir as 47 centres selected lamivudine/tenofovir as

their only choice.their only choice. 12 selected lamivudine as their only choice, 12 selected lamivudine as their only choice,

ie ie notnot in combination with tenofovir. in combination with tenofovir. One selected tenofovir as their only choice.One selected tenofovir as their only choice.

Hepatitis C: Estimated PrevalenceHepatitis C: Estimated Prevalence

48 respondents estimated HCV prevalence 48 respondents estimated HCV prevalence among their HIV patients as 0-3%among their HIV patients as 0-3%

23 estimated 4-6%23 estimated 4-6% 10 estimated 7-9%10 estimated 7-9% 13 estimated >10%, including all 6 13 estimated >10%, including all 6

exclusively haemophilia centres. exclusively haemophilia centres.

Six did not know or did not answer.Six did not know or did not answer.

HCV ScreeningHCV Screening

Of the 100 respondents, 94 routinely screen all Of the 100 respondents, 94 routinely screen all adult HIV patients for HCV. adult HIV patients for HCV.

Among the other six, all screen injecting drug Among the other six, all screen injecting drug users and three screen homo/bisexual men. users and three screen homo/bisexual men. Three screen haemophilia patients, but this may Three screen haemophilia patients, but this may reflect whether the centre sees such patients.reflect whether the centre sees such patients.

HCV/HIV ManagementHCV/HIV Management

0

10

20

30

HIV unit Localhepatology/

gastroenterologyunit

Regionalhepatology unit

Joint hepatology/HIV clinic

Other Not sure / noanswer

HBV

HCV

0

10

20

30

HIV unit Localhepatology/

gastroenterologyunit

Regionalhepatology unit

Joint hepatology/HIV clinic

Other Not sure / noanswer

HBV

Num

ber

of c

entr

es

HCV Genotype TestingHCV Genotype Testing

38 centres genotype HCV in all co-infected 38 centres genotype HCV in all co-infected patients.patients.

40 genotype those being assessed for HCV 40 genotype those being assessed for HCV therapy. therapy.

One selected “other” and 21 did not know or did One selected “other” and 21 did not know or did not answer.not answer.

57 used full genotype testing, 2 used a type 57 used full genotype testing, 2 used a type 1/non-type 1 test and 41 weren’t sure or didn’t 1/non-type 1 test and 41 weren’t sure or didn’t answer.answer.

HCV Viral Load TestingHCV Viral Load Testing

61 respondents confirmed that HCV VL testing 61 respondents confirmed that HCV VL testing was routinely available in their units. was routinely available in their units.

15 said it wasn’t and 24 weren’t sure or didn’t 15 said it wasn’t and 24 weren’t sure or didn’t answer.answer.

Liver Biopsy in HCV Co-InfectionLiver Biopsy in HCV Co-Infection

27 respondents would offer liver biopsy to most 27 respondents would offer liver biopsy to most HIV/HCV patients unless contra-indicated. HIV/HCV patients unless contra-indicated.

A further 41 would offer biopsy to those being A further 41 would offer biopsy to those being considered for HCV therapy. considered for HCV therapy.

13 selected other options and 19 weren’t sure or 13 selected other options and 19 weren’t sure or didn’t answer.didn’t answer.

Restrictions on HCV TherapyRestrictions on HCV Therapy

20 respondents reported restrictions on the 20 respondents reported restrictions on the availability of HCV treatment for co-infected availability of HCV treatment for co-infected patients – 10 for most therapies, 10 for some.patients – 10 for most therapies, 10 for some.

16 mentioned funding restrictions (4 with 16 mentioned funding restrictions (4 with funding for IFN but not pegylated IFN)funding for IFN but not pegylated IFN)

6 mentioned lack of expertise6 mentioned lack of expertise 2 mentioned restrictions related to HIV 2 mentioned restrictions related to HIV

status.status.

HCV Waiting TimesHCV Waiting Times

Overall, 40 respondents reported waiting times for Overall, 40 respondents reported waiting times for HCV therapy for HIV patients of less than 3 HCV therapy for HIV patients of less than 3 months. 23 reported 3-6 months, eight reported 6-months. 23 reported 3-6 months, eight reported 6-12 months, two longer than 12 months. 27 did not 12 months, two longer than 12 months. 27 did not answer.answer.

Waiting times were longer in centres reporting Waiting times were longer in centres reporting restrictions on treatment access – of these, six restrictions on treatment access – of these, six (30%) reported waits of 6-12 months and two (30%) reported waits of 6-12 months and two (10%) of more than 12 months.(10%) of more than 12 months.

ConclusionsConclusions

Survey has shown support for BHIVA guidelines and Survey has shown support for BHIVA guidelines and yielded information about current practice regarding yielded information about current practice regarding HIV/HBV and HIV/HCV co-infection.HIV/HBV and HIV/HCV co-infection.

Areas of concern may include:Areas of concern may include: Six centres not routinely screening for HCVSix centres not routinely screening for HCV Restrictions on access to HBV DNA testing, HCV Restrictions on access to HBV DNA testing, HCV

RNA testing and HCV therapy; consequent impact RNA testing and HCV therapy; consequent impact on waiting timeson waiting times

Inappropriate choice of drugs in some centres Inappropriate choice of drugs in some centres treating patients with HBV/HIVtreating patients with HBV/HIV